The Affordable Care Act: Extending Coverage to Millions of Americans

A closer look at the $2.7 trillion spent on healthcare in the United States in 2011 reveals a system of extreme imbalances, characterized by excessive consumption of care on the one hand, and lack of access to necessary care on the other. The Affordable Care Act (ACA), outlined by Otis Brawley, MD, FACP, at the 2015 Breast Cancer Symposium, held in San Antonio, TX, from September 25 to 27, has helped to restore a semblance of balance to this system; however, great strides must still be made in order to decrease waste and improve the overall health of Americans.

“The ACA is undoubtedly hard for doctors, but it’s generally a positive for patients,” said Dr Brawley, Chief Medical and Scientific Officer at the American Cancer Society, and Professor of Hematology, Medical Oncology, Medicine and Epidemiology at Emory University in Atlanta, GA. “There is lack of coverage for patients with incomes below 100% of [the] poverty level, which is a huge concern, but there has been expansion of coverage for preventive care, and implementation of clinical trial coverage provisions for everybody, except those insured on Medicaid. That is a positive, but we would like to expand it further.”

As Dr Brawley explained, a trillion dollars, so far removed from quotidian values, can be a tricky concept to grasp. In 2011, the year Americans spent $2.7 trillion on healthcare, $1.1 trillion was spent on food. For every dollar of the US gross domestic product (GDP), 17.9 cents was spent on healthcare.

Despite this massive investment, however, outcomes have been less than impressive. For example, in infant mortality, white male life expectancy, and per capita healthcare costs, the United States does not compare well to Switzerland or Canada. Switzerland is second behind the United States in the per capita healthcare costs, with $5270 versus $8233, respectively, in 2010. Age-adjusted mortality rates in the United States are in the middle in comparison to what they are in Western European countries, most of which spend only 8% to 9% of their GDP on healthcare.

ACA Legislation

More payment reform than health insurance reform, the ACA does not effectively address many of the aforementioned issues of cost, said Dr Brawley. That is not to say, though, that it has not had a positive effect on patients.

According to Dr Brawley, the ACA brings insurance coverage to most patients (but not all), gives premium and cost-sharing subsidies, provides screening services without cost-sharing, and offers clinical trial protections for people on private insurance and insurance other than Medicaid.

Benefits to patients notwithstanding, the ACA poses distinct challenges for providers, including Medicare Value- Based Payment Modifiers, and penalties for hospital readmissions. There is also an Independent Payment Advisory Board.

In the 1300-page ACA legislation, the word “quality” appears 483 times. Despite the verbiage, however, Dr Brawley indicated that the ACA does little to bring about actual quality in care.

In 2014, Congress passed legislation to expand investment in quality and put a quality/cost grid into place, increasing penalties to doctors for not practicing medicine according to certain quality metrics, and offering a bonus (of up to 27%) for those who do.

“In 2013, under the old rule, two-thirds of hospitals received penalties of $280 million (0.3% of operating revenue),” said Dr Brawley. “Hospitals taking care of the poorest Americans were disproportionately penalized compared to those taking care of the wealthiest patients.”

The average penalty, he noted, was 0.45% for the poorest hospitals versus 0.21% for wealthier hospitals. Additionally, 41% of wealthier hospitals received no penalty at all, whereas only 14% of the poorest hospitals were exempted.

“We should consider assessing and applying quality adjustments within hospital cohorts based on patient income and education,” he stated.

Nevertheless, the ACA has done much to close the coverage gap. Under the ACA, the Congressional Budget Office has estimated that 29 million Americans will be uninsured in 2018. A sobering thought, Dr Brawley concluded, but it could be worse.

If not for the ACA, he said, 56 million Americans would be uninsured in 2018.